IN THE CIRCUIT COURT OF THE
IN AND FOR
JUDICIAL CIRCUIT,
COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
AFFIDAVIT
I,
, being sworn, certify that the following statements are true:
1. The number of minor child(ren) subject to this proceeding is
. The name, place of
birth, birth date, and sex of each child; the present address, periods of residence, and places
where each child has lived within the past five (5) years; and the name, present address, and
relationship to the child of each person with whom the child has lived during that time are:
* If you are the petitioner in an injunction for protection against domestic violence case and you have
filed a Request for Confidential Filing of Address, you should write confidential in any space on this
form that would require you to enter the address where you are currently living.
THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD #
Child’s Full Legal Name:
Place of Birth:
Date of Birth:
1 :
Sex:
Child’s Residence for the past 5 years:
Dates
(From/To)
Address (including city and
state) where child lived
Name and present address of
person child lived with
Relationship
to child
/present*
____/____
____/____
____/____
____/____
LAW OFFICES OF ROBERT L. BOGEN, P.A. * 2300 GLADES ROAD * SUITE 203 E * BOCA RATON, FLORIDA 33431 * (561) 394-6060
THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD #
Child’s Full Legal Name:
Place of Birth:
:
Date of Birth:
Sex:
Child’s Residence for the past 5 years:
Dates
(From/To)
Address (including city and
state) where child lived
Name and present address of
person child lived with
Relationship
to child
/present
____/____
____/____
____/____
____/____
____/____
THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD #
Child’s Full Legal Name:
Place of Birth:
Date of Birth:
:
Sex:
Child’s Residence for the past 5 years:
Dates
(From/To)
Address (including city and
state) where child lived
Name and present address of
person child lived with
Relationship
to child
/present
____/____
____/____
____/____
____/____
____/____
LAW OFFICES OF ROBERT L. BOGEN, P.A. * 2300 GLADES ROAD * SUITE 203 E * BOCA RATON, FLORIDA 33431 * (561) 394-6060
2. Participation in custody or time-sharing proceeding(s):
[ Choose only one]
___
I HAVE NOT participated as a party, witness, or in any capacity in any other litigation or custody
proceeding in this or any other state, concerning custody of or time-sharing with a child subject
to this proceeding.
___
I HAVE participated as a party, witness, or in any capacity in any other litigation or custody
proceeding in this or another state, concerning custody of or time-sharing with a child subject
to this proceeding. Explain:
a. Name of each child:
b. Type of proceeding:
c. Court and state:
d. Date of court order or judgment (if any):
3. Information about custody or time-sharing proceeding(s):
[Choose only one]
___
I HAVE NO INFORMATION of any custody or time-sharing proceeding pending in a court of this
or any other state concerning a child subject to this proceeding.
___
I HAVE THE FOLLOWING INFORMATION concerning a custody or time-sharing proceeding
pending in a court of this or another state concerning a child subject to this proceeding, other
than set out in item 2. Explain:
a. Name of each child:
b. Type of proceeding:
c. Court and state:
d. Date of court order or judgment (if any):
4. Persons not a party to this proceeding:
[Choose only one]
___
I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has physical custody or
claims to have custody, visitation or time-sharing with respect to any child subject to this
proceeding.
___
I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this proceeding has (have)
physical custody or claim(s) to have custody, visitation, or time-sharing with respect to any
child subject to this proceeding:
a. Name and address of person:
( ) has physical custody ( ) claims custody rights ( ) claims visitation or time-sharing
Name of each child:
b. Name and address of person:
( ) has physical custody ( ) claims custody rights ( ) claims visitation. or time-sharing
Name of each child:
c. Name and address of person:
( ) has physical custody ( ) claims custody rights ( ) claims visitation or time-sharing
Name of each child:
5. Knowledge of prior child support proceedings:
[Choose only one]
___
The child(ren) described in this affidavit are NOT subject to existing child support order(s) in this
or any state or territory.
LAW OFFICES OF ROBERT L. BOGEN, P.A. * 2300 GLADES ROAD * SUITE 203 E * BOCA RATON, FLORIDA 33431 * (561) 394-6060
___
The child(ren) described in this affidavit are subject to the following existing child support
order(s):
a. Name of each child:
b. Type of proceeding:
c. Court and address:
d. Date of court order/judgment (if any):
e. Amount of child support paid and by whom:
6. I acknowledge that I have a continuing duty to advise this Court of any custody, visitation or
time-sharing, child support, or guardianship proceeding (including dissolution of marriage,
separate maintenance, child neglect, or dependency) concerning the child(ren) in this state or
any other state about which information is obtained during this proceeding.
I certify that a copy of this document was [Choose only one] ( ) mailed ( ) faxed and mailed ( ) hand
delivered to the person(s) listed below on {date}
.
Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
_______
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated: ______________________
Signature of Party
STATE OF FLORIDA
COUNTY OF ________________________
Sworn to or affirmed and signed before me on
by
NOTARY PUBLIC or DEPUTY CLERK
[Print, type, or stamp commissioned name of notary or clerk.]
Personally known
Produced identification
Type of identification produced
LAW OFFICES OF ROBERT L. BOGEN, P.A. * 2300 GLADES ROAD * SUITE 203 E * BOCA RATON, FLORIDA 33431 * (561) 394-6060
.